Delivering Feeley – Ron Culley, Quarriers (Part 2)
28th June 2021
In part 2 of this pre-event opinion piece, Ron Culley considers how we move forward with the Feeley recommendations; how we do this with courage and with ambition to ensure that every citizen has what is needed to thrive. You can see part 1 here.
Delivering Feeley – Part 2
Although details on governance, conditions and bureaucracy are important in the current context, the bigger challenge is making change happened in a way that is commensurate with the ambition of the Feeley report.
We need to look at the recommendations as an ecosystem rather than cherry pick the bits we like – that’s the surest way to get to the lowest common denominator and that won’t leave us much to shout about. So whatever else happens, we need to be bold. Scotland is not short on good ideas – but often falls woefully short in turning those ideas into action.
So what is to be done? I claim no special insight but here are a few areas on which we might want to focus.
Build a coalition for reform. This is important, not just because of the focus on co-production and partnership within the Feeley report – although without that, everything else falls. My sense is that leaders at all levels need to work together, outside of their traditional communities, to create the energy and momentum required to drive the change. As the Chief Executive of a third sector provider and a former IJB Chief Officer, I know how much talent exists in those two communities. But we work in a system that situates leaders in different camps with competing interests. Scotland is too small not to draw on all of the talent. We need to facilitate a greater interplay and exchange of ideas – because historically that hasn’t happened.
As we proceed with reform, we should resist retreating to our trenches. We sometimes find it easy to lob rocks at those with whom we disagree or whom we think have not delivered on their promises. But that strategy seldom produces lasting change. So we need to reach out to create the momentum required to change the existing system. That will require patience, pragmatism, generosity and reasonableness. We need to build a broad coalition that takes responsibility for the delivery of reform.
Redefine the social contract. At its most basic, the Feeley report sought to reposition the social contract between citizen and state – and we now need to develop that conversation. I was pleased to hear that the Scottish Government has already committed to doing work in that space – to develop a social covenant or charter which will underpin the creation of a National Care Service. That is really important work.
The social contract that exists between the citizen and state defines the support arrangements that citizens can expect from government – and what they must contribute as citizens in return. In respect of healthcare, most citizens tacitly understand that we each contribute through general taxation based on our ability to pay, and in return receive healthcare free at the point of use. By contrast, there is no clearly defined social contract in relation to care: it sits at the heart of a much more complex public service offer which draws partly from the welfare state, from the NHS, from local authority commissioned support, from charitable fundraising and from direct/private funding from the citizen. The development of a social covenant has an opportunity to change that – to define the social contract more clearly in respect of care and support.
A relentless focus on involving people. Another phrase stolen from the report, it underlines the need for coproduction. Reaching back into my past career, I remember being impressed by a young disability rights activist (now an MSP don’t you know) who consistently advocated ‘nothing about me without me’. It’s a statement that’s impossible to argue against. And encouragingly, not many people now do. Yet we don’t always (some would say often) live up to that ideal.
Part of the reason for that is that it’s hard to retro fit that ideal into a system that mass produces service options. Self-Directed Support has chipped away at that but I’m not sure anyone claims it has been transformative – it was introduced when local authorities were having to make painful budget cuts imposed by central government; it has tended towards consumerism rather than citizenship (which product would you like to buy?); and it has heightened competition between providers (my product is better than yours).
So maybe we need to strip it back down to basics – to the conversation between the citizen and the social worker – and to give those two people the flexibility, permission and resources to coproduce good outcomes.
National and Local. The disquiet among local government leaders is understandable but we now need to work together to ensure local accountability exists within a national service. Councils do terrific work, but increasingly the ‘local’ needs to be expressed at community or neighbourhood level – that’s where the asset-based approach Christie talked about finds its true expression. The best local authorities are already driving this agenda, recognising that community empowerment, ‘total place’ planning, and a revitalised social contract with local citizens can create the conditions in which people can claim their personal autonomy and agency. It’s also the best route to tackling entrenched poverty.
So I think whatever happens to the statutory duty to assess need, councils will continue to have a crucial strategic role in health and social care. I should also say as an aside that the role of councillors in the work of the IJB will continue to be important, ensuring that there is a democratic voice at the decision-making table.
Identify the quick wins. This helps to grow momentum and build faith. And notwithstanding the elements of the Feeley report that are contested, there is broad consensus across the vast majority of the recommendations. We don’t need to wait for a shiny new National Care Board to be getting on with those. Indeed, some of the problems can be solved by just getting more investment into the system. The elimination of charging can be done relatively easily – it just needs money. An increase in the take-home pay of care workers can be done relatively easily – it just needs money. We can pause unnecessary tenders – that just takes good faith. So in order to build confidence, I would argue the Scottish Government could turn its hand (and its pockets) to these early initiatives.
Manage expectations. One of the great things about the Feeley report is that it situates reform with a human rights framework, focusing on the conditions that allow people to express their personal agency. That’s a framework that recognises a foundational idea about the value of support – it fires the autonomy of individual human beings. However, in moving beyond that expression of principle, practical challenges remain.
For instance, much was said in the Feeley report about widening eligibility for support and creating more of a focus on early intervention. Difficult to argue against that. But my sense (and I may be wrong here) is that a rights-based approach won’t fundamentally alter one of the elemental challenges with the health and social care system, namely that demand for services will normally exceed supply. To express that in different terms, there is currently a statutory responsibility for local authorities to assess need and then following on from that assessment, to determine whether those needs call for the provision of services. The second bit determines what access a person has to resources – in other words, it determines eligibility. Even though Feeley recommends a massive £400m investment to boost access to support, it won’t remove the basic fact of scarcity.
These reforms will undoubtedly improve people’s lives – but they won’t entirely eliminate unmet need and they won’t necessarily confer a right to resources.
Change the transactional culture. Despite the fact that Scotland is replete with examples of high-quality support, it sometimes feels like that happens despite our existing commissioning arrangements rather than because of them (many hold a special disdain for ruthless competitive tendering). So
how do we dismantle the machine?
We begin by exchanging ideas and contributing to debate – and that’s already happening through CCPS, IRISS, IJB Chief Officers and so on. Some local partnerships have gone further and started to reimagine how commissioning should work. For instance, I recently met with the Director of the Glasgow Alliance to End Homelessness and was very encouraged by his ambition, where the combined wisdom of providers and commissioners will stimulate a programme of reform and make practical changes to improve the way support arrangements are put in place.
But we shouldn’t doubt the amount of organisational change that will be required. For example, many third sector organisations have become adept at responding to tenders. Over time, will these organisations need to become more attuned to the mindset of a commissioner, to participate in endeavours like the Glasgow Alliance? And how can we develop cultural change within the procurement teams of local authorities or IJBs, and furnish them with new tools to promote collaboration and blunt the effects of competition?
Evidence. Innovation. Improvement. I’m wary of importing the culture of the health service into the social care system, particularly in respect of the monumental amount of information that is produced, sliced and diced. The NHS is measured to within an inch of its life. But the converse is also true – without good data about the impact of support on people’s lives, about the professional experience of care workers, then we’re feeling our way in the dark. Without good data, we hold no evidence, and with no evidence, innovation goes unnoticed. And when innovation goes unnoticed, sustained improvement is impossible. A coherent offer of improvement support is therefore crucial.
Fair work. One of the questions I put to politicians in the pre-election period was whether they would back a 4% pay increase for care workers this year (the living wage increase is just 2.2%) and therefore match the offer that was put to better-paid NHS staff. I didn’t get very far, with most sidestepping the direct question. Even applying the Scottish Government’s own pay policy would be nice, which sees those earning less than £25,000 receive a pay increase of at least 3%, with a guaranteed cash increase of £750. So it’s time to move beyond the rhetoric on this and really deliver. We also need to better understand the proposals around national bargaining.
Truthfully, I’m not sure how that can work when you have hundreds of employers, each with their own decision-making processes. So, on that front, I expect a watered-down version of national bargaining – the government will offer funding on the condition that the recipients (care providers) abide by certain wage levels.
Courage. It’s difficult to step into the unknown, into unfamiliar territory – particularly with doubts about whether the new system will be better and safer than the one that went before. So we need courage. But I remain optimistic about the future. There are too many talented people in the sector for it to founder; there are too many politicians who know we can’t stand still; there are too many people with support needs who have identified a route to improvement. Between us, I think we have what it takes.
All of this, of course, is set against much bigger political events – the forces of history and fate. The nation is recovering from a global pandemic and is split down the middle on constitutional reform. Public finances remain under strain, and no doubt the monumental amounts of public debt will by flagged by future chancellors as a cause for concern. Climate change has shifted from tomorrow’s problem to today’s.
So what is the place in this for the reform of social care? Well, for me, it says something profound about who we are and want to become. It says that our job, individually and collectively, is to create the conditions under which individual citizens can thrive.